Archive for the ‘mammography’ Category
- skin lesion
- inflammatory lymph node
- Phyllodes tumor
- medulary carcinoma
- mucoid carcinoma
- colloid carcinoma
- Skin lesions
- Inflammatory nodes
- fat necrosis
- previous surgery
- radial scar/CSL
- breast abscess
- composite opacity
- Sclerosing adenosis
- fibrocystic change
- skin lesion
- Invasive cancer
- breast abscess
- medical – heart failure
- fluid overload, etc.
- recent surgery
- Inflammatory carcinoma
0__ Incomplete: Your mammogram or ultrasound didn’t give the radiologist enough information to make a clear diagnosis; follow-up imaging is necessary
1__ Negative: There is nothing to comment on; routine screening recommended
2__ Benign: A definite benign finding; routine screening recommended
3__ Probably Benign: Findings that have a high probability of being benign (>98%); six-month short interval follow-up
4__ Suspicious Abnormality: Not characteristic of breast cancer, but reasonable probability of being malignant (3 to 94%); biopsy should be considered
5__ Highly Suspicious of Malignancy: Lesion that has a high probability of being malignant (>= 95%); take appropriate action
6__ Known Biopsy Proven Malignancy: Lesions known to be malignant that are being imaged prior to definitive treatment; assure that treatment is completed
CLINICAL HISTORY: [x] year old woman referred for stereotactic core biopsy of a cluster of indeterminate microcalcifications in the [left or right] breast noted on recent mammography at [place and date].
Technique: [x] breast stereotactic core biopsy. Unilateral [digital] mammography. Specimen radiography. Dated [x].
PROCEDURE: Preliminary grid localizing film confirms a [x] cm cluster of microcalcifications in the [location within the breast].
Following universal protocol, patient and site verification was performed with a “time out” prior to the procedure.
After obtaining informed consent, the patient was positioned prone on the stereotactic table and the target was localized with digital images. A [x] approach was used. The skin was cleansed with Chloraprep. Cutaneous and deeper subcutaneous anesthesia was achieved using [x] cc of 1% Lidocaine and [x] cc’s of 1% Lidocaine containing epinephrine respectively. A small scalpel incision was made. A 9 gauge ATEC probe was inserted and its accurate position confirmed with pre and post fire images on the first pass. A total of [x] core biopsy specimens were obtained.
[#of radiographs] specimen radiographs revealed calcification in [x] cores. Cores containing radiographically evident calcium were sent in one container of formalin and cores not containing radiographically evident calcium were sent in another container of formalin for pathologic analysis, results pending. A [x] clip was [x] deployed to mark the biopsy site.
Post procedure cranial caudal and medial lateral projections disclose the clip to be at the target site. There [ are or are no ] residual microcalcifications noted at the biopsy site.
Following the procedure, the wound was cleansed and compressed. Steri strips and sterile gauze were applied and the patient was given post biopsy instructions. She left the department in good condition. Dr. [x] was in attendance during the entire procedure.
CONCLUSION: Status post stereotactic core biopsy of [right/left]